The noteworthy improvement in managing cardiovascular risk over the last ten years can be attributed, at least in part, to narrowing in on specific risk factor thresholds for performance measurement. "However," the authors note, "current dichotomous threshold measures suggest that risk factor levels should fall below a certain target in the majority of patients (eg, BP <140/90 mm Hg), regardless of underlying cardiovascular risk, patient preferences, intensity of treatment, underlying disease severity, or regimen adherence. Yet the evidence does not fully support the 'treat-to-target' approach implied in current performance measures."

The study authors designed a BP performance measure that is associated with clinical action measures (systolic BP [SBP] <140 mm Hg/ diastolic BP [DBP] <90 mm Hg; or SBP <150 mm Hg/ DBP <65 mm Hg; or index SBP <150 mm Hg and receiving three moderate-dose BP medications; or patient received appropriate clinical action within 90 days). A marker for potential BP over treatment was also set (SBP <130 mm Hg/ DBP <65 mm Hg and receiving either ≥3 BP medications, started a new BP medication class within 90 days, or receiving an increased dose of BP medication within 90 days of the index BP).

The study looked at patients with diabetes in 879 Department of Veterans Affairs (VA) medical centers and outpatient clinics. Ninety-four percent of the 977,282 VA patients who qualified for the action measure of a BP below 140/90 mm Hg threshold passed. During the evaluation, 82 percent recorded BP less than 140/90 mm Hg and 12 percent registered with BP greater than or equal to 140/90 mm Hg (with appropriate treatment). Out of the 20 percent (197,291) who had a BP lower than 130/65 mm Hg, eight percent (80,903) of patients were potentially over treated. Over treated patients were found to be older, had lower mean index BP, were more likely to be men and have ischemic heart disease.

As for facility performance, the pass rates varied between 77 percent and 99 percent (P<.001) and potential overtreatment rates varied between three percent and twenty percent (P<.001).

The authors concluded that, "while 94 percent of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment."